Self-Referral/Optin – full details 07/22

- all fields marked with an asterisk '*' are required must be completed otherwise you will not be able to click the 'Submit to TalkPlus' button

Gender *

Ethnicity *

Religion (if none, enter 'none') *

Relationship Status *

Sexual Orientation *

Smoking *

Alcohol *

Drugs *

Do you have debt problems? *
YesNo

Do you have gambling problems? *
YesNo

Are you an Asylum seeker *

Please say where you heard about our service

ex-Armed Forces *
YesNo

Are you, or your partner, pregnant or do you have a child under 12 months old? (tick all that apply) *
PregnantPartner PregnantChild under 12 months oldnone of these

Do you have any accessibility requirements we should take into account when allocating appointment premises? *
YesNo

Do you have a long-term physical health condition? * If 'Yes' please describe
NoYes

Do you have any diagnosed learning disabilities/difficulties, developmental disorders or cognitive impairments that you would like us to be aware of? * If 'Yes' please describe the nature of this disability or difficulty
NoYes

Do you require TalkPlus to make any adaptations to enable you to access our service (e.g. an interpreter/large print)? * If 'Yes' please describe the nature of the adaptation you require
NoYes

Does your doctor know you are contacting us? *
YesNo

 

YOUR CURRENT DIFFICULTIES

Is the reason you are referring as a result of the recent coronavirus pandemic or related to it? * If yes, please describe.
NoYes

Please select your main problem *

Please give any further details that you feel would help us understand your current problem?

At present, what bothers you the most? *

 

YOUR GOALS

Bearing in mind that TalkPlus offers short term types of therapy, what would you like to achieve or be able to do differently at the end of your treatment?

Would you be interested in attending the next available course that teaches people practical coping strategies? *
YesNo

 

YOUR PREVIOUS or CURRENT HEALTHCARE
(e.g. CMHRS, CAMHS, Psychiatrist or other Therapist)

If you have previously been referred to a Therapist, Psychologist, Counsellor or Psychiatrist, could you please describe who you saw, when it was and what treatment/support you received?

Are you taking any medication for depression or anxiety? Please give details *
NoYes

 

Your answers to the following questions will help us assess your current condition. Your referral cannot be submitted until this section is fully completed.

Please indicate how often you have been bothered by the following problems over the last two weeks:

Little interest or pleasure in doing things *

 
Feeling down, depressed or hopeless *

 

Thoughts that you would be better off dead or of hurting yourself in some way *

 
If you have chosen 1,2 or 3 on the last question, please answer the following question:
Do you have any active plans about harming yourself?*

 

Feeling nervous, anxious or on edge *

 
Not being able to stop or control worrying *

 

PLEASE NOTE:
We may use and share non-identifiable data about your treatment to provide statistics on the performance and effectiveness of our service with NHS England, NHS Digital and the local NHS Clinical Commissioning Group relevant to your area.
Please check here to acknowledge your consent *Yes